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HomeMy WebLinkAbout1472A � • WORKERS'COMPENSATION DECL4RATION I hereby alHrm thot I ha�e o cert�fica�e of consent to aelf • ini�re,or o cert�fieote of Workers'Compenso��on Ineuronce,or �6Asa7o . �� a��,,,;f;�, ereof(Sac.3800,��bC.) �E�B�aEY.�,e3; APPLICATION FOR PERMIT Policy No.�Company • �1nd . . ❑c�,,;{;�a�,pv;�h„ebY f�,�;,n�a. . S E W E R • S E W A G E D I S P O S A L � �Certified copy�s filed with the counry bu�ldinq tnspecron COUNTY OF LOS ANGELES BUILDING AND SAFETY depAa r me tJ � � ' ' - �o�e "�2�r 86Applimnl -T. 'F�@eID811' � FOR APPLICANT TO FILL IN CONNECTION DATA � CERTIFICATE OF EXEMVTION FROM WORKER$' p�uonK, � . COMPENSATION INSURANCE � nDDaE55 srnnp� OEvrN (This�edion need not be completed if the work involaed by the i�iiTY MANHaE RF�E4ENCE ��p permit is for one hundred dollars(=100)or less.) PFAREST fYPf OF CONNFCTION IEHGTH FiQN I cenify�Fro� in the performance of the work for which this �Rpug. Y ��ree P� µ�TppL pormil is issued,I shall not amploy any person in any manner p_�.�. O�b/ � so as�o become subject lo�he Workers'Compenwlion Laws. pW�a Anden G � �a.��.�. ,�,�. o ' - '��� TRUNKPFRMIiNO. ROADI4RAVTNO. Do�e . . APPlicant � �ooRess • NOTICE.TO APMICANT: If; aRer mokia �his Certificote of AFFIDnVII w�iv[e EASEMENT RfCORD.iN51R.Np. OAIE 9 CITV TFL.NO. � ���mption, you should 6ecome subjeU ro the Workers' 1pe�sotion provisions of�he Lobor code,you must fortFwith � �scn��vriom �oTr+o� Hwv.pt sr.wnoeNrtac ._.hply with such provisions or this permil sholl be deemed revoked.� ' � , etocK TRA[T 35761 57ATEENCRO.KWAENT � � UCENSED CONiRACTORS DECIARATION ' ^p o�e�p�s. ffRMiT r�o. � SiZE Oi lOt NOW ON lOT I Fero6y affirm tha��l am licensed under provisions oi Chaptar ust a ' 9�(mmmencing wi�h Section 7000�of Division 3 of 1he 6usi- BuitDir+GS OuaC�s ness a�d Proiessions Code,and my license is in full force o�d !I{lCi. , COMYAROR �^Qem� COnB� C0�1NEC110NCHARG(fEE �;�8,,,�N�m�,. 474887 ���.c�ogs �34 .�u 822 Beechwood ��MBURSEMENTfEE ,�', co,,,,a«o�T. Freeman oo�e 8/26/86 �„Y Alta Loma TE�.�. 1 . gp� DiS�YiCll+O. GQOuv �„o ��oa. � BK PG ❑I am exem t u�der Sec. of the L.A.Co. S�A� ���� /� � P LICFNSE NO... 8� QA55 V �- f� PlumbinqCodeand/or$ec. ofthe �� OESCR�PiiONOFWORK �c[ FNA� U B.8 P.Code for the following reoson R�1MKS�EV�IFRCONNECTMlGTO - OO D�TE t.�-Y7 VAUDATION 6 SEv7iC TuaR,SEEv�GE niT pi N ' Y175�HD/OQ ORAiK�EIU FNAL 'Z DO}e MOUSE SfN4Y CONNKTING TO BY PYNA DI Y � $ignolure - ... . CONHECT ADD�fiONAt&OG.OR , OWNER-BUILDER DECLARATION W�ro�s�s�w[a , WERFLOW SEEPAGE%T,DRAIN�IELD I beroby affirm tha�I am e.emp�from�he Controcbr's license ExiN.,CESSPDOL,DRYWELL,MhNHOI.F �/ low for Ihe following reason(Secfon 7031.5�BUiSnAES Ofld P!O- MTER,REPMIR OR AB�NDpJ 1qUSE <� � f�Z A � Y/ORSCOdl�: � ��RORDi5DO5�l5VSiFM , ,�9,cs ewrcr af!he prperty,ar my emplcyees wi!h v+ayes as �• ° � • � � their sole compensalion,will do 1he work ond�he sf�utture � ^ �2 7�5� is no�inronded or offerod for wle(Seclion 701A,Buainess and Professions Code)." OWNER�S Pefrl'lif S Q "� •A�� ❑I,oa owner of the property,am exclusi�ely contraciing wirh AUTHORIZATION TOTAL FEE � p �'5�" Ilcensed comradon to conshuc�the projecf(Section JO41, �qAVE AT THIS 6ATE A CONTROO WITX 711f HE4FIN NANED COM1iA�T04 LO ' O(J.'�9�8 b Businass and Professions Code�. ca�N[a rHE neovE oEx++�aeo Fwsnn�ow[wr�c To i�+E P�atic sEwtR. CONSTRUCTION LENOING AGENCY v� , . I hereby oH'��m ihat�here fs o conseruction lending ogency S�GNEDTH�S d � DAYOF 19_ � for the performance of Ihe work fo� which this permit is ��q� OWNFFS�CENi issued(Sec.3097,Civ.C.). ` A�� � lender's Name - Le�der's Address I ce.��(y tho�I ho�e read th�s appl�coi�on ond s�ofe�hot the obove informa�ion is correct.I ogree�o comply wiih all Coun�y ord7no�ces ond S�ote lows raguloting Pl�mb�rp ond Sewers, ond hereby outhorize representotives of this Covnly to enter upon the above•menfloned poperly for inspecfion purposes. 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